Experience of splenic mass saving procedures in children

Splenic Mass Saving Procedures (SMSP) are used to prevent
long-term risks of splenectomy. In order to assess the current state
of SMSP in the surgery of the spleen, their efficacy and long term
results, we reviewed the records of 289 children operated for the
splenic lesion over a 15-year period. Splenectomy was performed in
all cases of hematological disorders, with hemolytic disorders making
up to 85% of the material. SMSP were effectively used in patients
with epidermoid cysts (n=13), pseudocysts (n=2), parasitic cysts (n=2),
hemangioma (n=1), and splenic injuries (n=14). The following SMSP
were performed: partial splenectomy or cystectomy of epidermoid cysts;
aspiration of parasitic cysts; unroofing and washing out the cavity
with 20% saline; outer wall decapsulation with oversewing of the splenic
wall of post-traumatic pseudocysts; suturing combined with ligation
of the splenic artery in injuries involving major hilar vessels; suturing
combined with excision of the emaciated lower pole. The postoperative
course was free of complications in this series. Radioscintigraphic
imaging and platelet counts showed preservation in splenic function
in the follow-up period. It is concluded that: 1) SMSP represent 11%
of splenic surgery in this series, 2) Non-splenectomy operations can
be safely and effectively performed in order to avoid long risks of
splenectomy, and 3) There is a variety of non-splenectomy operations
that can be done in relation with the underlying pathology of the
spleen.Material and Methods
Two hundred eighty nine children were operated for the splenic
lesions during the between 1984 and 1998. Hemolytic disorders comprise
85% of this material, followed in order of frequency by splenic injuries,
congenital cysts, thrombocytopenic purpura, myeloblastic syndromes,
hydatid cysts, post-traumatic pseudocysts and Casabach-Merritt syndrome.
Splenectomy was performed in all cases of hematological disorders.
SMSP were performed on 32 patients (11%) with congenital cysts (13
cases), parasitic cysts (2 cases), pseudocysts (2 cases), hemangioma
(1 case), hilar injuries (11 cases), and emaciation of the lower pole
(3 cases) (Table 1.).
The age of patients submitted to SMSP ranged from 2 to 14
years. The male/female ratio was 1,2:1. There was a predominance in
number of females over males in the benign <@147>tumors<@148> group
and of males over females in the trauma group.
Results
Seventeen patients were admitted with cysts, as follows: 13
epidermoid, 2 parasitic and 2 post-traumatic. One patient was admitted
with haemangioma. The size of the cyst ranged from 4 cm to 15 cm.
Left upper quadrant abdominal discomfort was the main symptom in patients
with large cysts. The enlarged spleen was palpable in 14/17 patients.
Imaging techniques were employed for diagnosis. These included ultrasonography
and CT scan. Ultrasonography accurately provided the diagnosis of
splenic cysts as confirmed by operative findings.
Hemisplenectomy was performed in 10 children with epidermoid
cysts and in one child with hemangioma. Three children with epidermoid
cysts underwent cystectomy. In two children solitary hydatid cysts
were emptied of their contents by aspiration, and the resulting cavity
was washed with 20% saline solution to kill the contained scolices.
Two children with pseudocysts underwent partial decapsulation and
oversewing of the outer wall.
All epidermoid cysts had trabeculated internal surface and
multiple septa. The cyst fluid was light yellow. Microscopic studies
demonstrated epithelial lining. Hydatid cysts had epithelial lining
without trabeculation. They contained crystal clear fluid as well
as mother and daughter cysts. Pseudocysts had no epithelial lining.
They contained fluid consistent with hematoma.
Fourteen patients were admitted following blunt abdominal
trauma. The diagnosis of splenic injury was established by ultrasonography
and computed tomography. Non-operative treatment initially followed
the diagnosis, but had to be discontinued due to the deterioration
of vital signs and laparotomy was undertaken. Eleven patients had
hilar injuries involving major segmental vessels. They were treated
by suturing, combined with ligation of the splenic artery. Three patients
with emaciation of the lower pole underwent hemisplenectomy.
Postoperative recovery was free of complications in all the
patients submitted to SMSP. Splenic function was routinely screened
at 3-6 months after the operation. Platelet counts were normal. Radionuclide
scans demonstrated normal uptake in this series, including the patients
with ligated splenic artery.
Discussion
SMSP are enabled by the arterial network of the spleen and
its anatomical arrangement. As it has been described by many authors,
the hilar branches of the splenic artery are further divided into
5 or more branches, supplying the splenic parenchyma in a segmental
fashion. The segmental vascularization of the spleen allows splenorrhaphy
of transverse tears on the one hand, and partial splenectomy on the
other hand (1, 7, 8, 10).
Partial splenectomy was performed on patients with epidermoid
cysts, solitary hemangioma and injuries with emaciation of the lower
pole. The main steps of the operation were: ligation of the segmental
artery, mobilization of the spleen, sharp incision of the capsle,
transsection on the demarcation line using the finger, hemostasis
of the intraparenchymal vessels and suturing of the raw surface by
either mattress or continuing sutures. No stapler was used in our
patients (10). Not all epidermoid were dealt with by partial splenectomy.
Instead, cystectomy was performed in 3 cases, by resection of the
major portion of the cyst leaving behind a small part of the cyst
wall (8).
The collateral circulation of the spleen is derived mainly
from the superior polar artery (which occurs within less than 2 cm
before the bifurcation of the splenic artery in children), the short
gastric arteries, and the left gastroepiploic artery whose branches
traverse the gastroepiploic ligament. Additionally, minor vessels
traverse the ligaments and peritoneal attachments of the spleen. If
the spleen has not been mobilized and the splenic ligaments are intact,
ligation of the splenic artery is permissible. In children, it was
found that the spleen is visualized in radioscintigraphies after the
ligation of the splenic artery in the hilum or the ligation of one
of its branches (3, 4, 6). It was also demonstrated, by means of arteriographies,
that the collateral arterial network develops rapidly after the ligation
of the splenic artery (5). Finally, in experimental animals, revascularization
was demonstrated by the development of small vessels bridging the
two parts of the ligated artery (2). The ligation of the splenic artery
as an adjunct to splenorrhaphy in rare injuries involving hilar vessels,
has the immunologic advantage of preserving larger splenic mass than
partial splenectomy. the latter is reserved for treatment of injuries
with emaciation of splenic tissue.
Unroofing of pseudocysts and oversewing of the capsule was
recommended by T o u l u k i a n (9) and gave excellent results in
this series.
Contrary to the recommendation that hydatid cysts should be
treated by splenectomy (or at least partial splenectomy), we treated
2 patients by mere aspiration of the contents and washing out the
cavity with 20% saline solution. This is the usual mode of treatment
of solitary hydatid cysts in other organs, such as the lungs and occasionally
the liver. Long term follow-up of 2 and 5 years respectively, confirmed
the efectiveness of this minor procedure on solitary hydatid cysts
of the spleen.
It is concluded from this material that the spectrum of indications
of SMSP is large. SMSP are widely accepted in the surgery of the spleen
and with increasing experience (11) some of them are now performed
by means of laparoscopy.

Keywords:

Category: Original scientific paper

Volume: Vol. 43, No 2, april - june 1999

Authors: D. C. Keramidas

Reference work:

DOI:

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Journal PAEDIATRIA CROATICA is the official journal of the Croatian Pediatric Society and Croatian Society of School and University Medicine. The editor is Children's Hospital Zagreb. It is published four times per year by Children's University Hospital Zagreb, Klaićeva 16, HR-10000 Zagreb, Croatia.Practicing pediatricians, pediatric subspecialists, neonatologists, family physicians, and other health care professionals that have children in their care.